Healthcare Provider Details

I. General information

NPI: 1669802849
Provider Name (Legal Business Name): PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 MAIN ST
JACKMAN ME
04945
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-668-4300
  • Fax: 207-668-7605
Mailing address:
  • Phone: 207-945-5247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LORI L. DWYER
Title or Position: PRESIDENT & CEO
Credential: ESQ.
Phone: 207-992-9200